The document discusses Thailand's development of a universal health coverage benefit package. It outlines the key steps Thailand took: 1) Establishing systematic processes for developing the package, involving stakeholders and using evidence-based criteria and health technology assessments. 2) Starting with a basic package focusing on primary care and high-impact services, then expanding over time as resources increased. 3) Introducing rigorous health technology assessment processes to evaluate new interventions, ensuring only cost-effective options were included.

1. The ‘universal health coverage (UHC)
cube’ conceived by the World Health
Organization (WHO) identifies three key policy
questions for public healthcare provision to
achieveuniversalhealthcoverage:whathealthcare
services should be covered (the depth)?; should
the whole population be covered or only certain
groups (the breadth)?; and what proportion
of the total cost should be covered under UHC
(the length)? (See Figure 1 below) The UHC cube
concept recognizes that there is a finite public
budgetandabalancebetweenthethreedimensions
mustbestruck.Awell-definedbenefitspackageis
central to addressing these questions, outlining
what healthcare services are covered, for whom,
and with what degree of financial coverage.
A health benefit package may first focus on key
prioritiessuchasprovidingcost-effectiveprimary
care services, including health promotion and
disease prevention interventions, and providing
life-saving or high-impact health services to all
patientswhoneedthem.Highimpactinterventions
may be provided at little or no cost to the user
to ensure access for all. The package may be
expanded to cover additional services once more
financial resources become available.
Yot Teerawattananon, Juliet Eames and Saudamini Dabak
policybrief
Technologies comprise around 50% of healthcare
budgets in low and middle-income countries
and there are an increasing number of high-cost
technologies available in the market that may
or may not be cost-effective. Public financing of
cost-ineffective technologies reduces resources
available for provision of cost-effective health
interventions. Maximized health can be ensured
byaclearandcarefullydevelopedbenefitpackage
that excludes cost-ineffective treatment options
in order to provide governments with good value
for money.
Astechnologiesadvance,previouslycost-effective
interventionsmaybeovertakenbybettertreatment
options. For this reason, benefit packages must
be consistently reviewed to ensure financial
sustainability and provide the greatest level
of healthcare, at the lowest cost. A systematic,
transparent and participatory process for defining
a health benefit package helps policy makers
to make appropriate decisions and ensure
accountability of decisions. Implementing these
principlesleadstoapackagethatisfairandefficient
and allows stakeholders to accept the legitimacy
of a package even when it does not satisfy their
personal priorities.
the essential component of a successful
universal health coverage program
Designing the Health Benefit Package:
Why define a health benefit package and how to
ensure its acceptability?
Population: who is covered?
Extend to
non-covered
Reduce cost
sharing and fees
Services: which services
are covered?
Direct
costs:
proportion
of the costs
covered
Indude
other
services
Current
pooled funds
Figure 1: Universal Health Coverage Cube (Source: World Health Organization)
Issue#10November2018

2. Until 2002, there were several public health insurance
schemesinThailand: the Civil ServantMedicalBenefit
Scheme (CSMBS), the Social Security Scheme (SSS)
for formal employees, the Social Welfare Scheme
which coveredthepoor,nearpoor,children,elderlyand
other deserving groups and the Voluntary Health Card
scheme which subsidized low income households.
These schemes covered about 70% of the population,
half of which were covered by the Social Welfare
Scheme. CSMBS offered the most generous benefit
package, while the other schemes provided limited
packages.
In April 2001, the government committed to expanding
health coverage to 100% of the population and
consequently, full-coverage was achieved on 1st
January 2002. Full-population coverage was attained
by using general taxation to expand the Social Welfare
Schemeandcovertherestofthepopulation. Theinitial
benefit package for the new scheme, named the ‘gold-
card’scheme,wasbasedontheSocialWelfareScheme
benefit package and drugs list, but excluded high
cost interventions such as cancer treatment, anti-ret-
roviral treatment, organ transplant, coronary bypass
surgery, as well as cosmetic care.
In 2002, the National Health Security Office (NHSO)
was established as the management agency for the
‘gold card’ scheme and the Board, chaired by the Minister
of Public Health, established a Subcommittee for
the Development of the Benefit Package and Service
Delivery (SCBP). The SCBP comprises stakeholder
groupssuchaspatientgroups,civilsocietyorganizations,
providers, relevant government agencies, and subject
experts.
Initially, the SCBP considered proposals for inclusion
ofinterventionsintothebenefitpackagefrommultiple
groups in an ad-hoc manner, with no explicit criteria
foradoptinginterventions.Thissystemwasinadequate
asonlyelitegroupswithaccesstothesecretariatcould
effectivelypresentproposalsandthisprocessresulted
in policies that did not represent the broader public
interest. There was also significant variation in the
quality of evidence presented to the Subcommittee.
In October 2003, the government introduced anti-retroviral
treatment into the benefit package without any
formal assessment. This policy put pressure on the
NHSO to include other high cost interventions in the
benefitpackage.Oneproposalcalledfortheinclusionof
Renal Replacement Therapy for End Stage Renal
Disease (ESRD). Realizing that including expensive
treatments without careful assessment would be
financially unsustainable, the NHSO, which purchases
health services, and the Ministry of Public Health
(MoPH),whichprovideshealthservices,commissioned
a range of research projects that included a needs
assessment, service readiness study, economic
evaluation and budget impact assessment.
These was completed in 2006 and treatment of
ESRD became the first intervention in Thailand
to be rigorously assessed before being included
in the benefit package in 2008. This event paved
the way for the establishment of systematic
decision-making processes for health benefit
package decisions in Thailand.
In2009,theSCBPrequestedtwoacademicbodies,
the International Health Policy Program (IHPP)
and the Health Intervention and Technology
AssessmentProgram(HITAP),todeveloprigorous
mechanisms and processes for using evidence
to inform decisions for the non-pharmaceutical
benefits package of the Universal Coverage
Scheme (UCS). The mechanisms and processes
for the non-pharmaceutical benefits package are
as follows (See Figure 2 below):
Seven groups of stakeholders nominate
interventions for inclusion in the
benefits package: health professionals,
patients, policy-makers, academics,
civil-society, industry and lay-people.
Proposals can include up to three topics,
one of which must focus on health
promotion or disease prevention.
Topicsareprioritizedbya‘selection
working-group’basedonsixcriteria
whichare:burdenofdisease,severity
ofthehealthproblem,effectiveness
of intervention, variation in current
practice, financial impact of the
disease on households and equity
and ethical dimensions including
whether the disease is rare or
disproportionally affects the poor.
This working-group is a subset of
stakeholders eligible to nominate
topics and excludes industry and
policy-makerstomitigateconflicts
of interests. The short-listed topics
are then presented to a Health
EconomicsWorkingGroup,whichis
responsible for overseeing the HTA
evidence generated, before being
reviewed by the Subcommittee.
Development of the health benefit package for
Universal Health Coverage in Thailand:
Page 2

3. Figure 2: Process for the development of the Universal Coverage
Benefits Package (UCBP). (Source: HITAP)
Similar processes exist for decisions made by the NLEM subcommittee regarding public provision of
pharmaceuticals, including requirements that HTAs are conducted for all high-cost medicines before their
inclusion in the medicines list. HTAs requested by both NHSO and NLEM subcommittee must be comprehensive,
comparing across pharmaceutical and non-pharmaceutical treatment options in line with the national
guidelines.
HTAs do not simply lead to the acceptance or rejection of an intervention from the health benefit package or
the NLEM but can inform the method and conditions of service provision to yield good value for money for
the government. For instance, manufacturers may submit price quotations to be used in HTA research. If the
HTA finds that cost per QALY is above the cost-effective threshold or that the intervention has a high budget
impact, then a process of price negotiation ensues to reach a price that is acceptable. When imiglucerase
was not found to be cost-effective for the treatment of Type 1 Gaucher disease albeit with low budget-impact,
the NLEM used the results from the HTA study to develop a cost-sharing model which allowed Imiglucerase to
be included in the NLEM. Under the arrangement agreed, the government pays for the treatment of a certain
number of patients, beyond which treatment costs are borne by industry.
UHC benefit package development
Participatory, Transparent, Evidence-based
and Contestable
7 groups of
Stakeholders
Nomination
of
interventions
Prioritization
Assessments
Appraisals
Decisions
• Cost-effectiveness
• Budget impact
Appeals by
stakeholders
Criteria:
a Magnitude &
severity of problems
b Effectiveness of
interventions
c Variation in prac-
tice
d Financial impact
on households
e Equity & ethical
dimension
• problem
of the marginalized
• rare diseses
The final list of priority topics, usually
less than 10, will undergo a full
Health Technology Assessment (HTA)
through which information on the
cost-effectiveness and budget impact
are derived. The incremental cost-
effectiveness ratio (ICER) of the
interventions is compared with the
threshold value per QALY gained. HTAs
areconductedbyindependentresearch
organizations including universities.
IHPP and HITAP are jointly responsible
for less than one-third of the proposals.
The funding for most of the HTAs
comesfromthepublicly-fundedHealth
Systems Research Institute (HSRI).
All HTAs must comply with
the National Methodological
and Process Guidelines
approved by the SCBP which
ensures comparability and
transparency of studies. The
guidelines require HTAs to
undergo a detailed external
peer-reviewofallspread-sheets
and assumptions,providing
a strong quality assurance
mechanism.
The output is presented to the SCBP
for consideration which then makes
recommendations to the National
Health Security Board (NHSB). The
NHSB makes the final decision on
the inclusion of the intervention in
the benefits package.
Stakeholders
Working Group
Researchers
Committee for
Benefit
Package
Development
NHSO Board
Page 3

4. • Establish clear mechanisms and systematic
processes, with ‘good governance’.
• Involve relevant stakeholders in all stages of
the processes.
• Formulate clear and concrete decision criteria
to increase accountability at every step.
• Ensuresufficient,andsustainablepublicresources
to support the mechanisms and processes.
• Ensure adequate investment in a committed
and accountable secretariat and high-quality
technical team.
• DistributeresponsibilityforHTAresearchamong
qualified and committed independent institutes.
• Use the results of the HTA for price negotiation
and link to the financial support, procurement,
and M&E aspects of the UHC system.
• Suksamran et al. Universal Health Coverage: Case
Studies from Thailand. Health Systems Research
Institute, 2012.
• Mohara et al. Using health technology assessment
for informing coverage decisions in Thailand. Journal of
Comparative Effectiveness Research. 2012.
• Chalkidou K, Glassman A, Marten R, Vega J, Teerawat-
tananonY,TritasavitN,Gyansa-LutterodtM,SeiterA,Kieny
MP, Hofman K, Culyer AJ. Priority-setting for achieving
universal health coverage. Bull World Health Organ. 2016
Jun 1;94(6):462-7.
• Teerawattananon Y, Tritasavit N, Suchonwanich
N, Kingkaew P. - Z Evid Fortbild Qual Gesundhwes.
2014;108(7):397-404.
• Youngkong S, Baltussen R, Tantivess S, Mohara A,
Teerawattananon Y. Multicriteria decision analysis for
including health interventions in the universal health
coverage benefit package in Thailand. Value Health.
2012;15(6):961-70.
• Glassman A, Giedion U, and Smith P (editors). What’s
In, What’s Out: Designing Benefits for Universal Health
Coverage. Washington D.C. Brookings, 2017.
About the authors
Acknowledgement
• Develop a comprehensive or complicated
health benefit package at the introduction of
UHC rather, start with a simple and cost-effective
package to ensure feasibility.
• Provideonlyvaguedescriptionsofthepackage.
General descriptions, such as ‘maternal and child
health services’ or ‘cancer treatments’ leads to
variationsinpackageinterpretationanddifferences
in care provided across health facilities.
• Let anyone with clear conflict of interest be
involved in the process.
• Allow HTA research and decision making to
be conducted by single persons or single group
of people.
Do’s and Don’ts when defining a health benefits
package:
References
ThispolicybriefisapartofaseriesreflectingonThailand's
experience of implementing universal health coverage.
ThisworkhasbeencommissionedbytheHealthIntervention
and Technology Assessment Program (HITAP) under the
auspices of the International Decision Support Initiative
(iDSI) funded by the Bill & Melinda Gates Foundation, the
Department for International Development, UK, and the
Rockefeller Foundation.
Juliet Eames is an Overseas Development Institute
(ODI) fellow working for the HITAP International Unit.
JulietfirststudiedPhilosophy,PoliticsandEconomics
from the University of Oxford, then attained an MSc
in Development Economics from SOAS, University of
London. Juliet contributes to HITAP’s work supporting
countries to conduct Health Technology Assessment,
particularly in Southeast Asia.
Yot Teerawattananon is the founder of HITAP in the
Thai Ministry of Public Health and a Visiting Professor
at theNationalUniversityofSingapore.Heisco-found-
er of the HTAsiaLink and the International Decision
Support Initiative (iDSI). He has published more than
130 journal articles and provided technical support to
countries in Asia and Africa.
Saudamini Dabak is a Technical Advisor at HITAP,
Thailand. She completed her Master of Arts from
the Johns Hopkins School of Advanced International
Studies (SAIS), USA, and holds
a Bachelor of Arts in Economics
from St. Xavier’s College, University
of Mumbai, India.
Contact: hiu@hitap.net • This policy brief can be downloaded from www.globalhitap.net
Do’s Don’ts